A sharp reversal in the trend for suicide among young Americans between 2003 and 2004 could be evidence that the tougher warning labels required on selective serotonin re-uptake inhibitors (SSRIs) and other antidepressants in the US are doing more harm than good, some psychiatrists believe.

Published in the February issue of Pediatrics, the US Center for Disease Control and Prevention’s (CDC) Annual Summary of Vital Statistics showed there were 1,985 suicides in the 10- to 19-year age group in 2004, compared with 1,737 in 2003. That was an increase of 14.3% in one year, while the suicide rate rose from 2.2 per 100,000 to 2.6 per 100,000.

Deaths from suicide among Americans under the age of 20 were up by 18.2% over the same period. For youths aged 14 to 19 years, the suicide rate jumped by 11% from 7.3 per 100,000 to 8.2 per 100,000; in the 10- to 14-year age range the increase was 8%, from 1.2 to 1.3 per 100,000. All of this contrasted with a steady decline in suicide rates among the under-20s since the early 1990s.

Rekindling the debate

The CDC data have rekindled the debate over whether adding stronger warnings to antidepressant labels in the US about a possible link to increased risk of ‘suicidiality’ (suicidal thoughts and behaviour) in children and adolescents was actually counterproductive.

Psychiatrists warned at the time that the policy could put young people with depression at greater risk by discouraging off-label prescribing or scaring candidates for therapy and their parents away from treatment. Data released by US pharmacy benefit manager Medco in September 2004 showed an 18% drop in the number of paediatric patients on antidepressants in the first quarter of that year.

Some US experts are convinced the reversal in suicide rates is down to more cautious prescribing in the wake of the labelling changes. Others offer a more qualified, but not much less damning, view. While drawing conclusions about causality from the CDC statistics would be premature, noted Dr David Shern, president of Mental Health America, other research had indicated a general relationship between the use of the newer SSRIs and decreasing suicide rates in the general population.

“We must therefore wonder if the Food and Drug Administration’s [FDA] actions and the subsequent decrease in access to these antidepressants in fact have caused an increase in youth suicide,” he commented, adding that the federal government “must move aggressively to comprehend any potential consequences of their actions on the lives of youth”.

Extrapolating from the CDC data is complicated by the timing and nature of the labelling amendments. While concern about antidepressant use in children and adolescents had been building over the previous year, the warning statements requested by the FDA from manufacturers of 10 antidepressant brands in March 2004 recommended closer monitoring of all patients for worsening depression or emergent suicidiality. In October 2004, the agency then directed manufacturers of all antidepressants on the US market to add a ‘black box’ warning to their labels about increased risk of suicidiality in children and adolescents.

Other commentators have pointed to a drastic shortage of child psychiatrists in the US as a possible reason for the sudden increase in youth suicides.

GlaxoSmithKline, which recently had to face down further allegations in the UK that it had distorted clinical trial data to cover up a link between its SSRI Seroxat/Paxil (paroxetine) and increased suicidal tendencies in the under-18s, declined comment on the CDC data, stressing that any related use of Paxil in the US would have been off-label at the discretion of individual physicians.